AGREEMENT between BROWARD COUNTY and Cummings ...

Exhibit 2
Page 187 of 379
FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CARRIER SENT TO DIVISION DIVISION REC'D DATE
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
DIVISION OF WORKERS' COMPENSATION
For assistance call 1-800-342-1741or contact your local EAO
Office. Report all deaths within 24 hours 1-800-219-8953 or
(850) 922-8953
PLEASE PRINT OR TYPE
EMPLOYEE INFORMATION
Name (First, Middle, Last) Social Security Date of Accident Time of
Home Address
Employee's Description of Accident (Include Cause of injury)
Street/Apt #:
City:
State:
Zip:
Telephone:
OCCUPATION
Cause of Injury:
DATE OF BIRTH SEX INJURY/ILLNESS THAT OCCURED PART OF BODY AFFECTED
Company
D.B.A.:
Contact:
Street:
City:
State : FL Zip:
EMPLOYER INFORMATION
FEDERAL ID NUMBER (FEIN)
NATURE OF BUSINESS
DATE FIRST REPORTED
POLICY/MEMBER NUMBER
Telephone Number: DATE EMPLOYED PAID FOR DATE OF INJURY
Employer's Location Address (if different)
Street:
City:
State: FL Zip:
Location # :
LAST DATE EMPLOYEE WORKED
RETURNED TO WORK
WILL YOU CONTINUE TO PAY WAGES
INSTEAD OF WORKERS’ COMP
LAST DAY WAGES WILL BE PAID INSTEAD OF
WORKERS’ COMP
IF YES, GIVE DATE RATE OF PAY PER
Hour
Day
Place of Accident (street, city, Zip) DATE OF DEATH (If applicable) Number of hours per day
Street: AGREE WITH DESCRIPTION OF ACCIDENT Number of hours per week
City:
State: Zip:
County of Accident:
Any person who, knowingly and with intent to injure, defraud, or deceive any employer or
employee, insurance company, or self-insured program, files a statement of claim containing
any false or misleading information commits insurance fraud, punishable as provided in s.
817.234. Section 440.105(7), F.S. I have reviewed, understand and acknowledge the above
statement.
____________________________________ _______
Employee Signature
Date
_______
Employee Signature
Date
Number of days per week
NAME, ADDRESS AND TELEPHONE OF
OF PHYSICIAN OR HOSPITAL
Physician:
Hospital:
AUTHORIZED BY EMPLOYER
CLAIMS-HANDLING ENTITY INFORMATION
1(a) Denied Case - DWC-12, Notice of Denial Attached 2. Medical Only which became Lost Time Case (Complete all required information in #3)
1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial Attached Employee’s 8TH Day of Disability _______ / ______ / _______
Entity’s Knowledge of 8TH Day of Disability ______ / _______ / _______
3. Lost Time Case - 1st day of disability ____ / ____ / ____ Full Salary in lieu of comp YES Full Salary End Date ______/ ______ / ______
Date First Payment Mailed _________ / _________ / _________ AWW ____________________________ Comp Rate ____________________________
T.T. T.T. - 80% T.P. I.B. P.T DEATH SETTLEMENT ONLY
Penalty Amount Paid in 1st Payment $___________ Interest Amount Paid in 1st Payment $__________
REMARKS:
INSURER NAME
INSURER Code EMPLOYEE'S RISK CLASS CODE EMPLOYER'S NAICS CODE
Service Co/TPA Code # CLAIMS-HANDLING ENTITY FILE #
Week
Month
Yes
Broward County Risk Management
115 S. Andrews Avenue, Suite 210
Ft. Lauderdale FL 33301 (954) 357-7200
Form DFS-F2-DWC-1 (08/2004)
A